Provider Demographics
NPI:1033326889
Name:MOHAMMED MIRADI MD INC
Entity Type:Organization
Organization Name:MOHAMMED MIRADI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRADI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-644-1483
Mailing Address - Street 1:PO BOX 2353
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91943-2353
Mailing Address - Country:US
Mailing Address - Phone:619-644-1483
Mailing Address - Fax:
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:STE 211
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-644-1483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53125207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM3903742OtherDEA #
=========OtherEIN
CABM3903742OtherDEA #
CAA53125Medicare ID - Type Unspecified